Journal of Patient Safety最新文献

{"title":"Increased Risk and Unique Clinical Course of Patient Safety Indicator-3 Pressure Injuries Among COVID-19 Hospitalized Patients.","authors":"Jennifer B Cowart,Jorge Sinclair De Frías,Benjamin D Pollock,Camille Knepper,Nora Sammon,Sadhana Jonna,Trisha Singh,Shivang Bhakta,Lorenzo Olivero,Shari Ochoa,Kannan Ramar,Pablo Moreno Franco","doi":"10.1097/pts.0000000000001276","DOIUrl":"https://doi.org/10.1097/pts.0000000000001276","url":null,"abstract":"BACKGROUNDThe COVID-19 pandemic introduced unique challenges to healthcare systems, particularly in relation to patient safety and adverse events during hospitalization. There is limited understanding of COVID-19's association with some patient safety indicators (PSIs).OBJECTIVESThis study aimed to investigate the impact of COVID-19 infection on the rate of PSI-3 events and its implications on quality metrics. We compared PSI-3 event rates between COVID-19-infected and uninfected patients and examined the clinical characteristics of COVID-19 patients experiencing PSI-3 events.METHODSThis is a retrospective study at Mayo Clinic hospitals between January 2020 and February 2022, analyzing patients meeting PSI-3 denominator eligibility criteria. PSI-3 events were identified using AHRQ WinQI software. Patients were categorized based on COVID-19 status. Patient demographics, characteristics, and PSI-3 rates were compared. A case series analysis described clinical details of COVID-19 patients with PSI-3 events.RESULTSOf 126,781 encounters meeting PSI-3 criteria, 8674 (6.8%) had acute COVID-19 infection. COVID-19-infected patients were older, more likely to be male, non-white, and had private insurance. PSI-3 rates were significantly higher in COVID-19 patients (0.21% versus 0.06%, P < 0.0001), even after risk adjustment (adjusted risk ratio, 3.24, P < 0.0001). The case series of 17 COVID-19 patients with PSI-3 events showed distinctive clinical characteristics, including higher medical device-related pressure injuries, and greater predisposition for head, face, and neck region.CONCLUSIONSAcute COVID-19 infection correlates with higher PSI-3 event rates. Current quality indicators may require adaptation to address the pandemic's complexities and impact on patient safety. Further research is needed to comprehensively understand the intricate relationship between COVID-19 and patient outcomes.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142261866","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"What Else Could It Be?\" A Scoping Review of Questions for Patients to Ask Throughout the Diagnostic Process.","authors":"Mary A Hill,Tess Coppinger,Kimia Sedig,William J Gallagher,Kelley M Baker,Helen Haskell,Kristen E Miller,Kelly M Smith","doi":"10.1097/pts.0000000000001273","DOIUrl":"https://doi.org/10.1097/pts.0000000000001273","url":null,"abstract":"BACKGROUNDDiagnostic errors are a global patient safety challenge. Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures.OBJECTIVESThe goal of the scoping review was to identify, summarize, and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process.METHODSMedline and Google Scholar were searched to identify question lists in the peer-reviewed literature. Organizational websites and a search engine were searched to identify question lists in the gray literature. Articles and resources were screened for eligibility and data were abstracted. Interrater reliability (K = 0.875) was achieved.RESULTSA total of 5509 questions from 235 resources met inclusion criteria. Most questions (n = 4243, 77.02%) were found in the gray literature. Question lists included an average of 23.44 questions. Questions were most commonly coded along the diagnostic process categories of treatment (2434 questions from 250 resources), communication of the diagnosis (1160 questions, 204 resources), and outcomes (766 questions, 172 resources).CONCLUSIONSDespite recommendations for patients to ask questions, most question prompt lists focus on later stages of the diagnostic process such as communication of the diagnosis, treatment, and outcomes. Further research is needed to identify and prioritize diagnostic-related questions from the patient perspective and to develop simple, usable guidance on question-asking to improve patient safety across the diagnostic continuum.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142211928","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Handing Off Electronic Prescription Data From Prescribers to Community Pharmacies: A Qualitative Analysis of Pharmacy Staff Perspectives.","authors":"Megan Whitaker, Corey Lester, Brigid Rowell","doi":"10.1097/PTS.0000000000001244","DOIUrl":"10.1097/PTS.0000000000001244","url":null,"abstract":"<p><strong>Objectives: </strong>The aims of the study are to understand the process of how community pharmacies handle electronic prescriptions (e-prescriptions) and learn about different errors or potential errors encountered.</p><p><strong>Methods: </strong>Fifteen remote, semistructured interviews were conducted with community pharmacy staff. Interview analysis was done with two adapted Systems Engineering Initiative for Patient Safety methods to understand the workflow and an affinity wall, which led to key words that were tallied to understand the frequency of different issues.</p><p><strong>Results: </strong>Data entry in community pharmacies is a process that varies based on the different software platforms receiving e-prescriptions. Data entry of a medication product is typically a human-reliant process matching an e-prescription with an equivalent medication product. Current automated safety supports focus on matching the dispensed medication to the medication chosen at data entry. Substitutions may be required for a variety of reasons, however, pharmacists' comfort and permissions in doing so without provider involvement fluctuates.</p><p><strong>Conclusions: </strong>Prescription errors remain that could be prevented with additional support at the data entry step of e-prescriptions. Few studies demonstrate where these errors originate and what role current technology plays in contributing to or preventing these errors. Future work must consider how these matches between prescribed medications and pharmacy fulfilled medications occur. There is a need to identify potential tools to support data entry and prevent medication errors.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11335435/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140922495","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Detection of Adverse Events With the Austrian Inpatient Quality Indicators.","authors":"Marten Schmied, Wolfgang Buchberger, Dieter Perkhofer, Irma Kvitsaridze, Wolfgang Brunner, Oliver Kapferer, Uwe Siebert","doi":"10.1097/PTS.0000000000001235","DOIUrl":"10.1097/PTS.0000000000001235","url":null,"abstract":"<p><strong>Objectives: </strong>Indicators based on routine data are considered a readily available and cost-effective method for assessing health care quality and safety. The Austrian Inpatient Quality Indicators (A-IQI) have been introduced in all Austrian public hospitals as a mandatory quality measurement. The purpose of this study was to assess the value of conspicuous A-IQI in predicting the presence of adverse events (AEs).</p><p><strong>Methods: </strong>We conducted an exploratory study comparing all indicator-positive patient cases contributing to 18 conspicuous A-IQI indicators to randomly selected indicator-negative control cases regarding the prevalence and severity of AEs. Structured medical record review using the Institute for Healthcare Improvement Global Trigger Tool was used as the gold standard.</p><p><strong>Results: </strong>In 421 chart reviews, we identified 158 AEs. 70.9% (n = 112) of the AEs were found in cases with a positive indicator. The relative risk of an AE occurring was 3.47 (95% confidence interval: 2.30, 5.24) in indicator-positive cases compared to indicator-negatives. The proportion of severe events (National Coordination Council for Medication Error Reporting and Prevention Index categories H and I) was 54.5% (n = 61) in indicator-positive cases and only 15.3% (n = 7) in indicator-negative cases. Overall sensitivity of the A-IQI was 68.2%, specificity 69.4%, positive predictive value 36.0%, and negative predictive value 89.6%.</p><p><strong>Conclusions: </strong>Our study shows that significantly more AEs and more severe AEs were found in cases with positive A-IQI than in indicator-negative control cases. However, studies with larger numbers of cases and with larger numbers of conspicuous indicators are needed for the validation of the entire A-IQI indicator set.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141076954","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Visitor Restrictions During the COVID-19 Pandemic and Increased Falls With Harm at a Canadian Hospital: An Exploratory Study.","authors":"Stephanie Shennan, Natalie Coyle, Brittany Lockwood, Giulio DiDiodato","doi":"10.1097/PTS.0000000000001237","DOIUrl":"10.1097/PTS.0000000000001237","url":null,"abstract":"<p><strong>Background: </strong>Falls with harms (FWH) in hospitalized patients increase costs and lengths of stay. The COVID-19 pandemic has resulted in more FWH. Additionally, the COVID-19 pandemic has resulted in increased patients in isolation with fewer visitors. Their relationship with falls has not been previously studied.</p><p><strong>Methods: </strong>This is a retrospective, single-site, 12-month before pandemic-12-month after pandemic, observational study. Multiple logistic regression analysis was used to model FWH outcome and associations with isolation and visitor restrictions.</p><p><strong>Results: </strong>There were 4369 isolation events and 385 FWH among 22,505 admissions during the study period. Unadjusted analysis demonstrated a FWH risk of 1.33% (95% CI 0.99, 1.67) in those who were placed in isolation compared to 1.80% (95% CI 1.60, 2.00) in those without an isolation event ( χ2 = 4.73, P = 0.03). The FWH risk during the different visitor restriction periods was significantly higher compared to the prepandemic period ( χ2 = 20.81, P < 0.001), ranging from 1.28% (95% CI 1.06, 2.50) in the prepandemic period to 2.03% (95% 1.66, 2.40) with no visitors permitted (phase A) in the pandemic period. After adjusting for potential confounders and selection bias, only phase A visitor restrictions were associated with an increased FWH risk of 0.75% (95% CI 0.32, 1.18) compared to no visitor restrictions.</p><p><strong>Interpretation: </strong>Our results suggest a moderately strong association between hospitalized patient FWH risk and severe visitor restrictions. This association was muted in phases with even minor allowances for visitation. This represents the first report of the adverse effects of visitor restriction policies on patients' FWH risks.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141452008","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Role of Pediatric Nurses During Preventable Adverse Event Disclosure: A Scoping Review.","authors":"Jessica R Sexton, Susan Kelly-Weeder","doi":"10.1097/PTS.0000000000001239","DOIUrl":"10.1097/PTS.0000000000001239","url":null,"abstract":"<p><strong>Objectives: </strong>Preventable adverse events (PAEs) occur across the healthcare spectrum; and, unfortunately, errors, adverse events, and PAEs are common in pediatric care. Historically, the role of disclosure of PAEs to patients and their families occurred between the dyad of physician and patient, with physicians assuming the responsibility of disclosure. In recent years, a trend toward a multidisciplinary team-based approach has emerged in some institutions, yet the role of pediatric nurses within the team disclosing a PAE is not fully understood. Given the unique relationship between pediatric nurses and their patients and their families, it is essential to understand does the literature tell us about the role of pediatric nurses during PAE disclosure?</p><p><strong>Methods: </strong>The Arksey and O'Malley scoping review method guided this study protocol and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework guided reporting.</p><p><strong>Results: </strong>The final sample included five articles for synthesis: none reported or described a specific role for pediatric nurses during PAE disclosure.</p><p><strong>Conclusions: </strong>There is a gap in the literature on the role of pediatric nurses during PAE disclosure. Two themes emerged from this review: the use of a team-based approach to disclosure, and the need to provide emotional support to the pediatric patient and their family. There is a need for additional investigation into the role of pediatric nurses as part of a team-based disclosure process and how pediatric nurses currently provide, or desire to provide, emotional support to the patient and their family.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140922640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Independent Double Checks in the ICU: A Word of Caution.","authors":"Luca Cioccari, Lara M Hersberger, Alessandro Ostini","doi":"10.1097/PTS.0000000000001249","DOIUrl":"10.1097/PTS.0000000000001249","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141307232","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Falls in the Operating Room: Why Is This Still a Problem in 2024?","authors":"Allison Pellegrino, Karolina Brook","doi":"10.1097/PTS.0000000000001248","DOIUrl":"10.1097/PTS.0000000000001248","url":null,"abstract":"<p><strong>Abstract: </strong>Despite advances in patient safety, perioperative patient falls continue to be a persistent and preventable harm. Patient falls in procedural areas have been associated with multiple postoperative complications such as additional falls, functional decline, and hospital readmissions. Although fall-related databases exist, the specific number of periprocedural falls is difficult to ascertain, and the causes of such falls also remain elusive. We explore various solutions and recommend the creation of a national, focused database of periprocedural falls that will allow institutions to track numbers of falls in patients receiving anesthetic care and to identify the most common etiologies to enable the implementation of targeted strategies to prevent falls. Lacking this, we suggest specific screening and procedural recommendations during all phases of anesthetic care to increase providers' awareness and vigilance surrounding patient falls.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141471839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The \"Double Victim Phenomenon\": Results From a National Pilot Survey on Second Victims in German Family Caregivers (SeViD-VI Study).","authors":"Stefan Bushuven, Milena Trifunovic-Koenig, Victoria Klemm, Paul Diesener, Susanne Haller, Reinhard Strametz","doi":"10.1097/PTS.0000000000001251","DOIUrl":"10.1097/PTS.0000000000001251","url":null,"abstract":"<p><strong>Introduction: </strong>Second-victim phenomena may lead to severe reactions like depression or posttraumatic disorder, as well as dysfunction and absenteeism. Medical error as a cause for second victims is not limited to professionals, as family caregivers care for millions of patients at home. It remains unclear whether these are first, second, or double victims in case of error. This explorative study investigated whether second victim effects and signs of moral injury are detectable in family caregivers and whether existing instruments are applicable in lay persons.</p><p><strong>Methods: </strong>In an open convenience sampling online survey, we recruited 66 German family caregivers. Propensity score matching was conducted to obtain a balanced sample of family caregivers and qualified nurses who took part in the previous study by adjusting for age and sex. The groups were compared regarding the German Version of the Second Victim Experience and Support Tool-Revised and the German version of the Moral Injury Symptom and Support Scale for Health Professionals.</p><p><strong>Results: </strong>Sixty-six caregivers participated, of whom 31 completed the survey. Of all, 58% experienced a second victim-like effect, 35% experienced a prolonged effect, and 45% reported to still suffer from it. In a matched sample (22 family caregivers and 22 nurses), no significant differences were observed between the groups.</p><p><strong>Discussion: </strong>Regarding the limitations of this pilot study, demanding for resampling in larger populations, we could show that second victim effects and moral injury are detectable in family caregivers by validated instruments and are not inferior to professionals' experiences. Concerning the demand for further studies, we confirmed the applicability of the testing instruments but with need for item reduction to lower response burden.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141761935","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative Study.","authors":"Mohammad Farhad Peerally, Susan Carr, Justin Waring, Graham Martin, Mary Dixon-Woods","doi":"10.1097/PTS.0000000000001238","DOIUrl":"10.1097/PTS.0000000000001238","url":null,"abstract":"<p><strong>Objectives: </strong>The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. We aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterize the nature of the risk controls proposed.</p><p><strong>Methods: </strong>We undertook a content analysis of 126 action plans of serious incident investigation reports from a multisite and multispeciality UK hospital over a 3-year period to identify the risk controls proposed. We coded each risk control against the contributory factor it aimed to address. Using a hierarchy of risk controls model, we assessed the strength of proposed risk controls. We used thematic analysis to characterize the nature of proposed risk controls.</p><p><strong>Results: </strong>A substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. Of the 822 proposed risk controls in action plans, most (74%) were assessed as weak, typically focusing on individualized interventions-even when the problems were organizational or systemic in character. The following 6 broad approaches to risk controls could be identified: improving individual or team performance; defining, standardizing, or reinforcing expected practice; improving the working environment; improving communication; process improvements; and disciplinary actions.</p><p><strong>Conclusions: </strong>The identified shortfalls in the quality of risk controls following serious incident investigations-including a 15% mismatch between contributory factors and aligned risk controls and 74% of proposed risk controls centering on weaker interventions-represent significant gaps in translating incident investigations into meaningful systemic improvements. Advancing the quality of risk controls after serious incident investigations will require involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning, all supported by a common framework.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141452007","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}